Achieving the True Promise of Interoperability Demands Actionable Intelligence

^{By Emad Rizk, MD, CEO Cotiviti}

Americans will soon have the ability to access their health care records on their smartphones under new federal data interoperability rules released in March. However, making this data meaningful and useful for patients and all health care stakeholders will require advanced analytics, real-time intelligence, and pairing of both clinical and financial claims data for a complete picture of the patient’s health.

The move toward interoperability is a major step for health care. In addition to being an industry-wide priority for years, this initiative gives consumers greater control over their medical information for the first time—empowering patients to send their data to whomever they want, whenever they want. It’s also a major milestone for patient rights.

Amid patient privacy and security concerns expressed by both payers and providers, health care stakeholders also need to ensure vulnerable populations are not only able to digest their health information, but can use this data in partnership with their physicians to improve their quality of life.

One emerging solution seeks to combine all relevant health care data—from clinical charts to claims to social determinants of health (SDOH), pharmacy orders, medication adherence history, and trends in laboratory results—to give patients and their providers a longitudinal view of patients’ health and health risks. It’s an approach that could not only strengthen care management capabilities, but also change the way in which health plans and health care providers pay for and deliver care.

Getting to a Single Source of Truth

This past February, Cotiviti unveiled Caspian Insights, a unified data and analytics platform that represents the most comprehensive data set in the health care ecosystem.

Caspian leverages longitudinal data from 40% of Americans and the majority of their providers, creating a single source of truth for health care data that has never been seen at this scale. By offering an all-encompassing view of members’ health history spanning multiple health plans, Caspian gives payers and providers access to actionable information that will be critical to advancing interoperability and quality care.

What is the role that longitudinal data combined with advanced analytics can play in a consumer-directed health care data environment? Here are three ways data and technology platforms such as Caspian Insights will strengthen value.

Combining data from disparate systems for a single patient view. Ultimately, the ability to access data from multiple systems in a single location will support the creation of a single patient identifier. This is critical because it ensures the right records are matched with each patient every time—significantly reducing the risk of patient harm. One survey found 38% of health care organizations have experienced an adverse health care event due to patient matching errors, in part due to duplication.

A single patient identifier also enables health care organizations to:

• Prevent lost productivity when health care organizations cannot access patient records quickly
• Establish continuity in care, which strengthens quality, reduces waste, and bolsters the patient experience
• Help eliminate data inputting errors that hold up claim processing and ultimately revenue
• Reduce administrative inefficiency and its associated cost burden

With the Caspian Insights platform, data from disparate systems can be paired with evidence-based guidelines to aid decision making at the point of care. The use of machine learning and natural language processing to derive insights from longitudinal data also empowers providers to make more informed decisions that advance population health.

Strengthening payment integrity. Payment integrity is one of the costliest, most complex challenges health plans face. Medicaid identified nearly $57.4 billion in improper payments in 2019—up from $36.2 billion in 2018—resulting from claims for ineligible patients or for services that were never provided. Meanwhile, improper Medicare payments totaled $28.9 billion in 2019.

Tackling the root causes of improper claim payments before claims are paid is the most effective way to ensure the right care is provided to the right member for the right price, based on the contract. But some claims are too complex to be auto-adjudicated by legacy claim systems. This is where AI-driven analytics come in. For example, the Caspian Insights platform helps solve complex end-to-end payment integrity challenges by applying clinical and coding algorithms that identify questionable claims and then prompt coding experts and nurses to review the claims before a claim adjudication decision is made. This reduces the risk of improper payment. It also helps to avoid instances of provider abrasion that occur when health plans identify overpayments through retrospective review and seek to recapture the amount paid.

Capturing a more nuanced view of member health. Two of the biggest obstacles health systems face in adopting SDOH programs are a lack of money and an inability to project a return from such investments, a recent survey found. This is especially true for not-for-profit hospitals and systems, which face a negative financial outlook due to low patient volume growth, increased bad debt, dwindling reimbursement rates, and the shift toward a larger Medicare population as Baby Boomers age. By establishing a comprehensive view of the clinical and nonclinical data that shape a patient’s health narrative, providers and health plans gain a bigger-picture view of all the factors that impact each member’s situation. From there, they can develop highly targeted, highly personalized interventions that improve health outcomes as well as quality of life.

It’s Time to Act

Advancements in health care data sharing and analysis not only drive the most appropriate care for vulnerable populations, but also help identify the factors that impede behavior change—critical factors in developing personalized approaches to care management. They also offer enormous potential to:

• Increase collaboration across the continuum of care while reducing provider abrasion
• Close gaps in care by assessing a complete view of a member’s medical journey
• Provide real-world evidence that is critical to post-market approval of new therapies and indications

By investing in tools that pinpoint where care interventions are most needed in real time, payers and providers can achieve the true promise of interoperability for the health of generations to come.

About the Author:

Emad Rizk, M.D., is president, CEO and chairman, Cotiviti, Inc (ceo@cotiviti.com).